ADMINISTRATIVE GUIDELINES FOR RESPONSE TO AN ADVERSE ANESTHESIA EVENT

The Risk Management Committee of the Harvard Medical School's Department of Anaesthesia developed a set of guidelines recommending administrative actions that should be taken immediately following an adverse anesthesia event. The guidelines are intended to limit patient injury from a specific event associated with anesthesia and to ensure that the causes of the event are identified to prevent recurrence. The guidelines direct the primary anesthetist to concentrate on continuing care but quickly notify someone in a leadership position, who would become the ''incident supervisor. '' The incident supervisor would be knowledgeable of the details of the protocol and direct activities for ensuring appropriate medical care, sequestration of equipment, documentation of information, and contact of other appropriate administrative personnel. Experience with the guidelines has shown that they can be effective if applied but that it is difficult to do that consistently in our large medical centers.